I remind you that any medical information provided in these
reports is just that…information only!! Not medical advice!! I am
not your doctor, and decisions about your health require
consultation with your trusted personal physicians and consultants.

The information I provide you is to empower you
with knowledge, and I have repeatedly asked you to be the team
leader for your OWN healthcare concerns. You should never act on
anything you read in these reports. I have encouraged you to seek
the advice of your physicians regarding health issues. Feel free to
share this information with family and friends, but remind them
about this being informational only. You must be proactive in our
current medical environment.

Don’t settle for a visit to your doctor without them giving you
complete information about your illness, the options for treatment,
care instructions, possible side effects to look for, and plans for
follow up. Be sure the prescriptions you take are accurate
(pharmacies make mistakes) and always take your meds as prescribed.
The more you know, the better your care will be, because your doctor
will sense you are informed and expect more out of them. Always
write down your questions before going for a visit.

Thanks!! Dr. Sam

February 4 was World Cancer Day.
9 million people around the globe die of cancer each year. As
a cancer survivor since 1991, I am living proof that early detection
increases cure rates. Get screened and don’t ignore persistent
symptoms. Be wise and help those who might be denying issues that
are potentially serious!

Most people do not understand the difference between ligaments,
tendons, and fascia. They are all protein fibrous connective tissues
that connect bones and joints, and cover muscles and provide
support.

These tissues can be injured causing pain and inflammation.
Injuries are defined as sprains and strains. A
sprain is an injury to ligaments
whereas a strain is an injury to muscles
or tendons. Degrees of strain or sprain imply tears in these
tissues.

This report will limit the discussion to 2 common injuries:
tennis elbow (epicondylitis) a
tendonitis (-itis emplies inflammation), and
plantar fasciitis, technically a
fascial layer but similar to a tendon that is sprained (some degree
of tear). Both present with the same symptoms—pain, swelling, some
redness (inflammation), and disability.

The inflammatory process is the normal way the body heals
injuries. The body sends white blood cells (mast cells and
macrophages) to clean up the injury secreting certain chemicals to
dissolve the damaged tissue cells, and also increases blood supply
to assist in healing by bringing increased oxygen an injured area,
and hopefully provide healing of the injury. Unfortunately, some of
these injuries are resistant to healing and are easily reinjured
before they have time to completely heal. When healing is not
complete, scar tissue and degeneration occurs causing continued
symptoms and vulnerability to re-injury.

This discussion involves 2 common injuries difficult to
heal—tennis elbow and plantar fasciitis.

A. TENNIS ELBOW (EPICONDYLITIS)

Any sport or
activity using the hand to grip (tennis, golf, carpentry, baseball,
etc,) can cause this injury. An example of a tendon injury is tennis
elbow or technically called epicondylitis (tendonitis), an injury
from many activities. The forearm muscles insert into tendons into
outside projections of bone (epicondyle) of the humerus (upper arm
bone) at the elbow. If that tendon tears even slightly, it will
cause severe pain with use. Inflammation in the tendon occurs and is
difficult to heal. The drawings below show the anatomy and where the
injury occurs (lateral epicondyle is the projection of the outside
of forearm bone (humerus).

The initial treatment is rest,
use of a band or strap over the area to splint it from movement when
using the hand, ice compresses 3-4 times a day, and
anti-inflammatory medications (Aleve, Ibuprofen, etc.). When the
area has time to settle down (1 week or more), gentle exercises to
stretch this tendon are recommended (see drawings below). Cortisone
injections may be necessary, and in rare cases (5-10%), surgery to
release the entire or part of tendon from the epicondyle, and then
let it heal with new scar tissue. Patience is the hardest part.

Tennis elbow pathology shows inflammation from a tear in the
tendon at the epicondyle--extensor radial muscles(forearm)
attachment. Below is a drawing of the inflammatory process that
occurs in this tendonous attachment, and either an endoscopic
approach or open procedure may rarely need to be performed to
relieve the issue. Below are drawings of these approaches.

A boney spur may be present after
repeated injuries and can be removed when the tendon is repaired.
Rehabilitation must include gentle stretching exercises as shown
below.

There are numerous alternative therapies that can successfully
treat tennis elbow, and I will discuss them when reporting on
plantar fasciitis later in this report.

Below are the classic exercises necessary to strengthen the
forearm and stretch the tendons associated with tennis elbow. These
exercises are a necessary part of the treatment protocol as it
heals.

For tennis elbow, a strap just in front of the tendonitis will help
splint the area to reduce movement when using the hands.

These splints can be purchased at drug stores, WalMart, and sports
facilities.

B. PLANTAR FASCIITIS

This is a very painful inflammation in the bottom of the foot
usually occurring in front of the heel or even in the heel. 85% of
those affected are working age (25-65) and this injury affects about
10% of the population. 22% are runners and 65-75% of those afffected
are overweight.

The injury occurs where the plantar fascia inserts into the heel
bone (medical name is calcaneus). With too much tension pulling on
the fascia from the toes, mini-tears occur at this insertion of the
fascia. Point tenderness is usually present and a tender fullness
may be felt just in front of the heel from swelling. For runners, it
is excessive overuse from over-pronation of the foot. Over time and
repeated inflammation, a bone spur
may form. Over a million visits to doctors and podiatrists occur
every year.

Plantar fascia

Tears closer to the bone!

What is the plantar fascia?

The plantar (means foot) fascia is made up of a group of 3 tissue
bands on the bottom of the foot made of collagen (protein). It is
quite similar to tendons and ligaments which all support bones and
joints. As stated, the fascia originates behind the toes and inserts
onto the heel bone (calcaneus).
When it is strained (torn), it causes inflammation usually where the
fascia inserts on the heel (see above drawings) bone, causing severe
pain just in front of or in the heel, especially as one first stands
on the foot, which may become less severe after walking several
steps. It is more likely to occur in overweight people, those with
tight calf muscles, high arched feet, those who wear poorly
supported shoes, and those very active in sports especially runners.

The plantar fascia acts to provide support of the arch (preventing
flat foot) and also acts as a shock absorber for the foot. Over time
and reinjury, a degenerative process occurs with thinning of the
fascia. Aging also thins the heel pad aggravating the issue.

Orthoticsand instep support in shoes is critical to prevent and treat
this injury. These orthotics are best recommended by a specialist or
a store that sells special sports equipment designed to prevent
these injuries (there are foot stores now). If over the counter
orthotics are not helping, please see a podiatrist or orthopedist
who has special training in foot and ankle disease, but expensive
custom made orthotics are not thought to be much better than ones
that can be purchased over the counter. Certainly follow the advice
of the specialists.

An orthotic that
goes on your foot and can then be used in a variety of shoes is
available at WalMart, online etc. called Strutz. ($ 8.00 and it
helped me).

Physical therapy
consults may be very helpful . In certain cases,
steroid injections (cortisone)into the site of pain can relieve the problem. If an
injection is performed, care must be taken for a few weeks to not
overdo exercise as this area is vulnerable to rupture and further
damage and pain. 3 steroid injections 2-4 weeks apart are the
maximum amount that is recommended in any one year.

Time is a critical factor in
healing these injuries and will take a few months to be resolved.

Night splints for plantar fasciitis
to keep gentle stretching on the plantar fascia (flexing the big
toe) may be helpful as well.

Icing 3-4 times a day with or
without heat at other times is often recommended using an ice pack
that contours to the bottom of the foot. Rolling the foot over an
ice pack (or frozen bottle of water) back and forth will compress
the plantar fascia with stretching and help with pain and swelling
at the focus of the inflammation.

Alternative treatments

There are many alternative
treatments today that have some value, and most of these treatments
have mixed research results but are aggressively marketed.

For best results, it is the combination of anti-inflammatory
medications, steroid injections (to reduce inflammation), time, care
not to reinjure the area with movement, special taping, orthotics,
physical therapy with massage, and stretching, that will provide
resolution in as many as 90% of the cases. For resistant cases,
these alternative methods may be valuable.

Stem cell injections are being
used, but the research is not yet in on these expensive experimental
treatments.

Cryotherapy uses a probe
introduced through the skin that freezes the area, which may
stimulate new healing.

Acupuncture with or without electrical stimulation
techniques have been successful in some cases.

Blood or platelet rich plasma (the patient’s own)
into the area causes an inflammatory process that may stimulate the
healing process. This applies to tennis elbow as well. The photo
shows injecting the blood into the joint of the arm.

ESWT—Extracorporal Shock Wave
Therapy is an FDA cleared (not approved) new technique for tennis
elbow and plantar fasciitis that may have value. The apparatus sends
high pressure sound waves that stimulate blood flow to the area and
reduce inflammation by creating new tissue injury thus allowing the
body to heal the site. It is too soon to know if this is the future
for any tendonitis or fasciitis. This also applies to tennis elbow.
These techniques are not covered by most insurance companies.

Surgical Management—Fasciotomy—for plantar faciitis

If a heel spur is
present, this may require surgical removal if plantar fasciitis
recurs. 90% resolve with conservative measures no matter what
measures are taken. Below is a drawing showing removal of a heel
spur and partial removal of the degenerated tendon. This can be
performed endoscopically or as an open procedure.

Considering the smaller incision with endoscopic surgery, it would
seem reasonable to seek out a specialist in this procedure.
Orthopedic surgeons perform many endoscopic procedures.

Medicine is an inexact science. It is important for patients to
know the solemn responsibility physicians accept in the care of all
patients regardless of any personal social and political ideologies
they have. This has become much more important with the influx of so
many races, colors, creeds, religions, etc.

In a crisis, just as in hurricanes, healthcare professionals do
not discriminate when people are in distress and reaching out for
help. It is commonly
quoted that the Hippocratic oath states, “when in doubt, do no
harm”, however, although those words are not actually in the oath,
the spirit of it is. Physicians go into medicine to help people!

Medical Errors

The issue of medical errors is a difficult area to discuss. It is
not easy to admit a mistake for anyone especially when it pertains
to caring for patients. Doctors make mistakes and learn from them
like all professionals, however, physical and or psychological harm
can come from these errors, and with the legal profession on alert
at all times, doctors pay not only financially but suffer
psychological pain knowing they made a mistake and caused harm.

Medical practice presents a constant challenge to clinicians,
because the variables each patient present with are so different
even with the same disease. How a patient presents with an illness,
how they respond to treatment, how well they follow the doctor’s
orders, and how other co-morbidities (other diseases the patient
has) affect the outcome of illness, determines the outcome of any
treatment. It is also this challenge that draws a person to choose
the medical profession. It is why I chose the medical profession
(yes, even with all the barriers in the current medical
environment).

The challenge of continually updating a physician’s knowledge

Keeping up with medical advances is a huge challenge but the
responsibility of every physician. Doctors must present to the
Florida Board of Medical Licensing 30 hours of continuing medical
education credits every odd year to keep an active medical license.
For initial licensing and renewals, 2 hours of education regarding
prevention of medical errors is required.

Writing THE MEDICAL NEWS REPORT each month has allowed me to
update my knowledge in most fields in other than my own head and
neck specialty much more than when I was in practice. (my specialty
was Ear, Nose, and Throat Surgery, Facial Plastic, Cosmetic, and
Reconstructive Surgery, Head and Neck Cancer Surgery). During my 30
years of practice, I had to learn new techniques and innovations in
my field leaving little time for staying up on other fields of
medicine. Can you imagine trying to stay up with all the information
a primary care doctor has to? That is why they must rely on
specialists when medical issues get complicated.

The medical profession is expected to be error-free, and they are
not. No wonder there are more referrals to specialists today for
fear of missing an underlying disease. And yet there are insurance
companies and major medical centers that dock a primary doctor’s pay
if they request too many consults.

That is where the responsibility of the patient should come in,
because doctors are being forced to see more patients to make up for
decreasing reimbursement or required as an employee. It is no time
to be a “passive” partner because assisting the physician in one’s
own healthcare has never been more important. That is why I share
these reports with hundreds of people to empower them to learn more
about their medical conditions. My reports are just the beginning to
encourage patients to do their research about the illnesses they
suffer from and be knowledgeable when they have a doctor’s visit.

Side effects of treatment

With new drugs and treatments that manipulate the body’s immune
system (for example), side effects have mounted. Reading about
potential side effects of medications be taken should be every
patient’s responsibility. Drug interactions increase with taking
multiple medications. A person over 70
years of age takes an average of 6 different medications per day.

What is evidence-based medicine?

The government and national medical organizations have, by
necessity, begun to provide
evidence-based medical and surgical guidelines for most major
diseases because doctors can’t keep up with all the medical advances
as the pace of medicine continues to increase in speed. These
guidelines, however, are just that…they are not laws on how to
practice medicine. They are only guidelines but cannot take every
variable into consideration for each patient. That is why, at the
end of the day, deciding medical plans are between patients and
their physicians, and not bureaucratic organizations that can only
provide guidance based on sound medical research. I have spent the
last 7 years helping write these guidelines for the American Cancer
Society regarding screening for cancers.

Missing a diagnosis, choosing the wrong treatment, contending with
side effects of treatment, managing other illnesses that affect a
treatment, knowing when to refer to a specialist, and realizing
something is going wrong takes experience and knowledge. When a
treatment is not working, alternatives must be decided on, and when
in doubt, doctors should reach out for other opinions. And yet, when
something goes wrong, patients quickly lose confidence in their
doctor and start the blame game.

These difficult times are best handled with the truth about an
error that might have inadvertedly occurred. Trying to cover up a
mistake is the worst thing a doctor can do. Being honest is the best
policy. Doctors are human and make mistakes. That is why doctors
with a good personal relationship with their patients are less
likely to be sued.

Malpractice

Malpractice is a dirty word, but that is what it is called. There
are times when mistakes are made, and in this litigious society,
someone will likely pay. There are areas in medicine that come with
much more hazard than others.

Informing patients about risk is the responsibility of any doctor,
and understanding it is the patient’s responsibility. It is critical
for patients to study on their own health issues, and these reports
are a good place to come to as a resource. Trusting the internet is
tricky and often unreliable. Patients want to rely on their doctors
to make decisions, but the patient needs to help guide the doctor’s
decisions with thoughtful questions, following orders, and informing
them immediately when there is a problem.

Unnecessary treatments and defensive medicine

In one study, 20.6% of all
medical care was considered unnecessary as reported by a number of
physicians across all specialties. In addition, 22% of
prescriptions, 24.9% of tests, and 11.1% of procedures are
unnecessary according to these physicians.

Reasons given for these figures are: fear of litigation and the
pressure from patients to over-treat, difficulty accessing patient
records, lack of adequate information from patients and previous
treating doctors, and pressure from healthcare facilities that
doctors are controlled by as an employee.

Fear of malpractice

Fear of malpractice continues to be a serious issue on how doctors
practice medicine raising the cost of healthcare as pointed out by
the above figures.

Lawyers have marketed their profession well and have successfully
placed in most people’s minds that if something goes wrong in
treating a patient, that they want to sue especially when the
lawyers do not charge plaintiffs upfront and collect their fees only
if they win. Somewhere in the middle must be reached if we are ever
to get a handle on healthcare costs from defensive medicine
practices. Medscape, November 28, 2017

Many medical errors occur in the hospital due to the complexity of
the illnesses treated. The Washington Post, cited an article in the
British Medical Journal, that medical
errors are the third leading cause of death in the U.S. (251,000)
behind heart disease and cancer.

Medication errors

Medication
mistakes are the most common error in
the hospital. 1 in 5 patients will experience a medical error in
their lifetime. Consider the number of prescriptions Americans take
(1.3 billion in 2016), the number
of illnesses and procedures performed, and now the U.S. population
exceeds 323 million people (2016 statistics). Patient safety should
always be a shared responsibility between medical personnel,
patients, and families. Patients must report side effects so that
their physician can deal with them and make sure it is posted in the
medical record.

CMS (Centers for Medicare and Medicaid Services) is addressing
this issue in one way by reimbursing doctors and hospitals based on
quality of care rather than fee for service. Now more than ever,
patients must do everything they can to improve their health by
stopping unhealthy habits, lose weight, and follow doctor’s orders.

Medical errors occur every day and even though they may be
relatively minor, they are unacceptable and must be reported and
corrective action taken.

There are potential medical errors inherent in medical care
delivery. There is a difference in an accidental medication error
and operating on the wrong side of a patient. One article stated
that there are still 40 operations per week that are performed on
the wrong side. These are easily preventable with operating room
standards, and yet they continue. I would like to know what kind of
a facility is that careless knowing the strict rules in place in
operating rooms.

Even though errors occur on a daily basis, consider there are
950 million doctor visits per year.
The stress of seeing more patients per hour and now adding the time
to document the visit in an electronic medical records, it sets up
an environment for errors on the chart, dosage of medications, and
forgetting to check if a patient is allergic to a group of
medications. Errors in electronic medical records will be
perpetuated easily for months and years until the error is
discovered and corrected as other doctors review these records.

Misdiagnosis

Missing a diagnosis is another
issue. With little time for examinations, problems can be overlooked
or missed. X-rays can miss small cancers, and EKGs could miss an
intermittent cardiac irregularity. Patients often do not bring
symptoms to their doctors or are untruthful about their habits.

Hospital based deaths

Deaths can occur with
complicated illness especially in the hospital and are the third
leading cause of death in the U.S.—200,000 per year. Bed sores,
hospital based infections, blood clots, embolism, surgical errors,
and complications from treatments all account for this statistic.
Most are not preventable but many are!

Changing how physicians and hospitals are being reimbursed

Medical errors are part of the reason that insurance companies
(particularly Medicaid and Medicare) are changing the reimbursement
method for hospitals and physicians to a
quality of result payment. For instance, readmission to the
hospital from a complication may not be covered regardless of cause.
Medicare payments to hospitals and doctors may be reduced for not
meeting quality standards or now not having an electronic medical
record. It is no wonder that more and more physicians are fed up and
have decided to become employees rather than weather private
practice and all the regulations that have strangled healthcare.

There are plenty of critics regarding this information, but here
is why I bring it up…..be aware of these issues and team up with
your physician to help ensure medical errors do not occur. Check
your prescriptions and dosages, know when to take your medicine,
read about side effects and immediately report them to your doctor,
take medications only as prescribed, and never stop a medication
without discussing it with a physician. A patient needs to know
about their own health issues! Patients must question diagnoses and
treatments. Ask the doctor about expectations of a treatment, the
potential complications, and recovery time for a surgery or medical
treatment. Also if a patient is older, make sure an elective
procedure is really necessary and what success can they expect.
Never let an elderly patient see a doctor without a family member
present to hear instructions.

Physicians need to admit and apologize for errors. Having a good
relationship with a patient is critical for understanding and
prevention of lawsuits. Doctors are human but when accepting the
healthcare of patients comes they accept a huge responsibility, but
patients have responsibilities too, and we can all team up to reduce
these errors. Medscape, WebMD, BMJ

Report on medical malpractice in 2017

Medical malpractice continues
to increase the cost of medical care. Unfortunately, the majority of
physicians will be sued one or more times during their career. Many
doctors are paying over $100,000 a year for malpractice insurance
per year, and it impacts the cost of healthcare.

Lawyers have forced the insurance companies to settle out of court
most of the time to prevent a lengthy expensive trial, and doctors
are many times forced to go along with the insurance companies even
when they are not actually negligent and settle out of court. The
lawyer ads on TV alone tell the story.

There are cases where actual negligence and incompetence deserve
compensation for physical and emotional disability, and plaintiffs
are increasingly being rewarded for “pain and suffering”.

The following are the results of the analysis of 4000 physicians
over all specialties reported in the internet journal, Medscape. The
impact on the physicians and patients having to endure a lawsuit is
often overlooked, but it has created
defensive medicine in this country and needs to be reformed.
Lawyers receive 40% of most lawsuit judgments, whether they go to
court or settle out of court. All parties want to settle and how
lawsuits are litigated must be changed. Arbitration boards should be
the answer and they are in some cases as is mediation.

Class action suits are part of Big Pharma’s cost of doing
business, and they pass the costs on to the patients. The same is
true for hospitals. Doctors can’t charge more because most
insurances will only pay a certain predetermined amount based on
coding.

More than half of all physicians are sued at sometime in their
practice. Physicians may be sued individually or be involved in
multiple physician lawsuits including hospitals and other medical
facilities.

85% of general surgeons and OB/Gyn doctors experience a lawsuit
with 70% plus of ENT, Urology, Orthopedics, Radiology, and Plastic
Surgery are named in a suit. Almost half of these specific
specialties experience 2-5 lawsuits during their career. I had one
lawsuit in 30 years while in practice, but paid premiums for
malpractice insurance for all 30 of those years.

It is thought by many that doctors who have lawsuits are inferior
in quality, however, many times these doctors have higher risk
patients that are more likely to have complications. This is
especially true in large referral medical centers.

87% of physicians were very surprised or somewhat surprised when
they were named in a suit with only 13% not surprised.

Breakdown of lawsuits

-31% of the suits arose from a missed or delayed diagnosis.

-27% arose from complications of surgery.

-24% from a poor outcome of a treatment.

-17% from a failure to treat or delayed treatment.

-16% from wrongful death cases.

Time it takes for a lawsuit to finalize

It takes 1-2 years for a lawsuit to be resolved in 39% of the
cases and 35% take 3-5 years. 82-90% of suits are settled out of
court. Of those lawsuits who went to
court, only 2% favored the patient (this is why lawyers want
to settle).

Almost all physicians have malpractice insurance although in most
states, it is not required. Over half of
physicians were either coerced or required to settle the lawsuit by
their insurance carrier to prevent a trial because of the
extreme cost and years of work.

Plaintiffs were awarded up to $100,000 in 33% of the cases, with
35% up to $500,000.

How a lawsuit affects a doctor

Sadly, lawsuits change the way physicians view patients. 26% did
not trust their patients or viewed them differently. 6% quit
practice. However, only 30% felt that the lawsuit negatively
affected their overall career. It did not affect my practice but
certainly was a huge burden on me which I carried forward even
though the surgical complication was unavoidable in removing a
tumor.

Better chart documentation by
physicians was cited as the most likely to protect from future
lawsuits.

Impact of a lawsuit

The emotional impacton patients is obvious, but it may not occur to the public
what a devastating experience it is for
the physician. Defensive medicine is on the minds of most
physicians whether they are sued or not, but in this study,
over 45% of physicians surveyed had the
threat of a suit on their minds almost all of the time and one third
stated it influenced the way they treated patients often
ordering more tests, requesting more frequent visits, and generally
feeling they needed to do more than they did if the threat of a suit
wasn’t present. And yet, only 16% of physicians turned away a high
risk patient.

Better communication with patients was
cited as the most important way to prevent litigation!

Over two thirds of physicians feel that medical organizations are
not doing enough to reduce lawsuits.

1 in 26 Americans will
experience one or more seizures in their lifetime. 3.4 million
Americans are living with a seizure disorder and there are 150,000
new cases each year, according to the Epilepsy Foundation. www.epilepsy.com

It is important to note that epilepsy and seizures are not exactly
the same. There are many types of seizures that are much more subtle
than the classic grand mal seizure with the classic jerking
movements. Two main categories include
partial and generalized seizures.

1--Definition of a seizure

A seizure is abnormal electrical event in the brain and can be
seen on an EEG. It usually occurs from an abnormal focus of
electrical activity in one of more specific areas in the brain.
Seizures are categorized by the activity observed during the event
and the syndrome is called epilepsy. Below is an EEG
(electroencephalogram) with brain waves that are normal and one that
demonstrates seizure activity.

2--Definition of epilepsy

Epilepsy is seizure activity
with certain motor or sensory signs and is a collection of signs and
symptoms called a syndrome that are recurrent. There are many people
who just have one seizure and never have epilepsy, which implies
recurrence of episodes of activity including electrical seizure
activity.

3--Common types of seizures

There are 30 types of seizures. The most common 3 categories are:

a) focal seizures (partial)—60% of seizures

b) generalized seizures—40%

c) mixed

a) Focal (partial) seizures

These seizures are subclassified into
simple and complex. They are frequently defined by the area
of the brain that is involved (i.e. frontal lobe or temporal lobe
seizure). Temporal lobe seizures are the most common type of focal
seizure.

—simple partial seizures

These simple partial seizures can involve a very small area of the
brain. Depending on the focus, a finger or hand may jerk or other
movements of one arm. The patient remains conscious but may
experience unusual feelings or sensations (smell, taste, sudden joy,
anger, visual, nausea, loss of hearing, feel numbness, or weakness).

—complex partial seizure

These complex seizures create an alteration or loss of
consciousness as opposed to the simple partial seizures. They are
defined by the area of the brain involved such as the frontal or
temporal lobe. They may be manifested by repetitive movements
(called automatisms) such as picking at the air, twitches, blinking,
lip smacking, making noises, repeating phrases, laughing
inappropriately, or even walking in circles. These movements are
involuntary.

As opposed to generalized seizures, if the extremities are
involved, they are only on one side of the body in focal seizures.
Because they involve areas of the brain that involve alertness or
awareness, they can result in daydream states and usually last only
a few seconds. If they were performing some act before they have
these seizures, they usually go back to that activity.

b) Generalized seizures

These seizures involve most of
the brain even if they start in one site. These seizures involve
both sides of the brain and are associated with staring into space,
jerking, or twitching movements, loss of consciousness, or falling
down. If somewhat limited in motion (eyes twitching, lip smacking,
etc., they were named petit mal
(“little seizures) in the past.

Genralized seizures may involve stiffening of the extremities
(tonic type) or repetitive movements (clonic
type) or both (tonic/clonic-grand
mal seizure are now called
myoclonic seizures. Their teeth may bite their tongue and
secretions (saliva) may spill from the mouth. They may or may not
stop breathing during the event. Many will fall to the floor losing
bladder and bowel control. These seizures usally can last up to 3
minutes but if over 5 minutes, it is a medical emergency and someone
must call 911. Following the seizure, the patient is usally in what
is called the “post-ictal” state,
feeling very drowsy and disoriented, with no memory of the seizure.

There are also atonic seizures in
which the person goes limp during the seizure and can be confused
with narcolepsy.

c) Mixed type of seizures

These seizures may begin as a
focal seizure and then progress into a generalized seizure.

Because there are so many types of seizures and many are mislabeled,
there is great misunderstanding in epilepsy.

4. Auras in seizures

These patients may have auras before having these seizures
(similar to classic migraines) signifying the seizure is coming.
Actually they are simple seizures preceding the complex partial
seizure and are usually the same each time. Migraines can have auras
as well.

5. Confusion with other disorders

These seizures can be confused with migraines, narcolepsy,
fainting, or even mental disorders called non-epileptic events.
Tourette’ syndrome and cardiac arrhythmias can be added to the list.

6. Absence seizures

A person begins this activity from 4-14 years of age and are
observed to appear staring aimlessly for a few seconds staring into
space with no recollection of the event. It can occur many times a
day. These seizures can go undiagnosed for years due to the subtle
nature and shortness of the episode. Parents may think they are just
not paying attention. Children usually stop these types of seizures
at puberty.

7. Causes of seizures

Most disorders may be caused by genetic mutations (hereditary),
lack of oxygen at some time from birth throughout life, strokes,
sudden high fevers (febrile seizures) infections of the brain, head
injury, or brain tissue alteration from a disease such as Alzheimers,
brain tumors, eclampsia, and acute withdrawal from alcohol. There
are at least 500 genes thought to
be involved in epilepsy.

8. Research

There is intensive research on neurotransmitter chemicals,
specifically GABA
(gamma-amino-butyric acid), which actually inhibits
neurotransmission, which may make the neurons less excitable.

Theory of how a seizure occurs

In a focus of brain tissue where a seizure begins, it is theorized
that there is damage to normal transmission of nerves, and abnormal
burst of activity create a chain reaction which then causes a
seizure.

There is research on the membranes of neurons, which are
responsible for a neuron to stimulate an electrical impulse. Glial
cells in the brain have some influence on nerve impulses too, since
they regulate chemicals in and out of the nerves.

9. Triggers for seizure activity

About one half of seizures have no known cause.

There are triggers to lower the
threshold. Certain poisons
(lead,carbon monoxide), stress,
lack of sleep, and even a flashing light or a change of menstrual
cycle can contribute.

Because of the obesity epidemic,
obstructive sleep apnea has become a significant risk factor
for seizure activity and recurrence, and it has now become necessary
for a neurologist to explore the possibility that sleep apnea may be
a trigger for seizure activity. Any cause that decreases oxygen to
the brain will increase the likelihood of seizure activity. CPAP
during sleep for apnea has been proven to decrease the number
seizures by as much as 50%. This is critical new information. Any
seizure patient should consider a sleep study to diagnose the
possibility of sleep apnea.

10. Epilepsy in children

Most children will grow out of the disorders and 70-80% will be
controlled with medication with an occasional breakthrough seizure.
The school and daycare must be aware to take special precautions.

Febrile seizures usually do not
recur (only 2-3% recur) and don’t need medication. Scientists have
discovered genes that predispose children to febrile seizures.

There are cases of drug resistant
seizures in young people under 18 who respond to
neurosurgical intervention especially with temporal lobe seizures.
They do have post-operative side effects which correlate with the
site of surgery, and memory loss was one of the more common issues
and some visual field loss. NEJM

11. Diagnosis

The EEG (electroencephalogram)
is the standard procedure to perform for diagnosing seizures.
Special techniques may be used to increase the likelihood of seeing
the abnormality on EEG. This test is a brain wave test which is
compared to a normal one.

CT and or MRI scans are often
performed to rule out tumors, congenital abnormalities, blood clots,
evidence of a stroke or scarred area.

Blood tests are used to rule out chemical abnormalities such as a
low blood sugar in a diabetic, lead, etc.

12. Safety during seizures and consequences of multiple seizures

One of the biggest concerns is
loss of cognitive and memory functions. Although most seizure
disorders do not cause major
intellectual disability, there are many developmental syndromes that
include a multitude of disabilities, they also may include seizures.
The high level disabilities are not caused by the seizures rather
they are the result of underlying neurodegenerative disease
complexes.

Driving privileges may be revoked for 6 months to a year if a
person is prone to recurrent seizures. This impacts the whole
family, work, etc. The law requires a person not drive for 1-2
years. The Florida law requires a patient be free of seizures for 2
years. For Georgia, it is 6 months. Periodic review of medical
reports from the neurologist is necessary regarding safety to
drive. For laws regarding each state, click on
www.epilepsy.com/driving-laws/2008686

Being seizure free for one year decreases the risk of an accident
by 93% in one study. Limitations in sports and other social
activities that may harm the patient or others must all be
considered.

Employers are prevented by law from refusing to hire those with
controlled epilepsy, however, one study cited that only a 57% of
patients with epilepsy graduate from high school and 15% finish
college.

Epileptic women who become pregnant have a 90% chance of
delivering a normal baby and a risk of about 4-6% of having a baby
with a birth defect.

14. Status epilepticus

Any seizure lasting longer than
5 minutes should be considered in status epilepticus, denoting
continuous seizure activity. This is a medical emergency. About 60%
of these patients have no history of previous seizures. 80% treated
within 1 hour are controlled, but after 2 hours, that figure drops
to 40%.

15. Risk of sudden death

There is a 2 fold increase in sudden death in these patients with
no explanation. It appears to occur more likely in those with 2 or
more medications necessary to control the seizures.

16. Treatment of Seizures

a) Need for seizure medication

Those who have a single seizure will need a neurological workup,
however, may not need seizure control medications. Depending on the
results of the EEG and scans, medication may not be started until a
person has a second seizure. One study found that after 8 years,
only 33% had a second seizure saving 2/3 of the patients from having
to take medication after that and having possible side effects of
the meds. 70% of patients can be controlled seizure-free with
regularly taking their medication.

b) Diet adjustment-ketogenic diet

A diet higher in fat with adequate amount of protein is used to
treat difficult to control epilepsy. This diet forces the body to
burn fat instead of carbohydrate. With metabolism, the liver is
forced into using the fat for energy and breaks down fats into fatty
acids and ketone bodies. This creates a
metabolic state of ketosis, and the ketone bodies pass into
the brain using this breakdown product of fat instead of glucose to
lower seizure activity. This will reduce half of the number of
seizures in half of children and young adults. There is also
evidence it may help in adults. A modified Adkins (high protein)
diet has also been effective. A dietician should be consulted in
these cases. Patients will experience constipation with these diets.

There are medical conditions that should use caution with this
diet—Crohn’s disease, cardiovascular disease, diabetes, chronic
fatigue syndrome, and severe acne.

c) Medication is the treatment
of choice for those with at least a second seizure and those without
a known cause. Clinical decision making is critical in these cases.

Carbamezapine (Tegretol) and
phenytoin (Dilantin) have become
the most popular medications because of their effectiveness over 2
barbiturates—phenobarbital (Luminal)
and primidone (Mysoline)
according to a VA Cooperative study especially for
tonic-clonic seizures (grand mal).

For partial seizures,
lamotrigine (Lamictal) and
oxycarbazepine (Trileptal) had
the best success.

For generalized seizures,
valproate (Valproic) and
lamotrigine (Lamictal) had the
most success cited in Medscape.

Monitoring the blood level of a drug is commonly performed to
monitor the progress of the treatment.

Once treatment is initiated, there is about a 60% success rate in
keeping the patient seizure free with one drug.

d) Side effects of medications

The main concern are side
effects including drowsiness, dizziness, and cognitive difficulties.
These may be short term or longer. Adjustment of dosage or switching
to alternate medications may be necessary. Gabapentin (Neurontin)
and livetiracetam have the fewest side effects.

Dosage adjustment in patients with kidney dysfunction may be
necessary. Some of the most effective drugs may cause elevations in
liver enzymes causing liver damage. Skin reactions can be severe.
Suicidal behavior may occur. Possible birth defects may be an issue
with pregnant women.

e) Inhibitor or inducer of seizure
medications

A blood test is necessary to detect CYP450, a genetic enzymatic
system in the liver that affects the dosage of seizure medications.
If the enzyme is present adjustment of the dosage is necessary.
These enzyme inducers also affect some contraceptives and an
anti-coagulant (Coumadin). There are other drugs that are
metabolized by the liver with a slightly different enzymatic system
(CYP450 and CYP3A4) that can affect seizure medications including
erythromycin (Z-pak antibiotic), diltiazem (Cardiazem a heart
medication0, and cimetidine (Tagamet for indigestion).

There is a new and improved
shingles shot, and it is recommended by the CDC even though you have
received the older version (Zostavax) in the past. It is recommended
to receive the new version (Shingrix),
since it is about 90% effective compared to 50% from the older
vaccine.

The shingles virus (proper name is herpes zoster) occurs from the
chicken pox virus (Varicella zoster) in childhood. The virus stays
dormant in the nerves just off the spinal cord only to be activated
later in life in the form of shingles. Vaccination in childhood
helps prevent the potential for developing shingles (herpes zoster).

The FDA recommends the vaccine for all people 50 and over (the CDC
recommends 60), all those immunocompromised, and those with chronic
disease (diabetes, heart disease, kidney disease, etc.).

Even if a person receives the new vaccine, people can still
develop the rash, but are much less likely to develop the terrible
complications from the shingles virus (post-herpetic neuralgia).

1 in 3 American adults will experience
the shingles virus which is a very painful blistering rash
usually seen on the side of the chest wall, however, it can occur on
the face or other areas of the body. 50% of cases occur in patients
over 50 years of age. 1 million
Americans will suffer from the virus annually. It can recur,
therefore, do not be fooled that if you have had the shingles, you
do not need the new shingles shot.

Characteristic Rash

The typical rash
is shown above commonly along the side of chest and abdomen in the
left photo, and on the right is an example of the appearance on the
face involving the eye and nose. This itchy, painful rash follows
the distribution of the skin nerves and does not occur on both sides
of the body simultaneously. As stated, the herpes zoster virus lives
permanently in the spinal nerve ganglion (just outside of the spinal
cord), and when activated, travels down the nerve ito the skin
nerves causing the eruption on the surface of the skin. Tingling,
skin sensitivity, and itching may occur. There is no medical way to
rid the body of this virus.

before the rash appears.

Spinal
ganglion

Serious complications of shingles

The Herpes zoster virus can cause permanent pain in the
area where the rash occurs in about 1 in 5 cases. This is called
post-herpetic neuralgia, a form
of neuropathy. Rarer complications include permanent blindness,
hearing loss, and facial paralysis (Ramsey-Hunt syndrome) when the
face is involved from invasion of the trigeminal nerve. In my
practice, I cared for many patients with facial shingles, and they
were difficult management cases requiring intravenous anti-viral
medication (acyclovir), corticosteroids, and hospitalization.

Prevention of these severe
complications are the most important reason for getting vaccinated.

Chicken pox patients develop shingles

The CDC recommends the vaccine whether
a person recalls getting chicken pox as a child or not.
Shingles can’t be transmitted to other people unless a person has
not had chicken pox as a child. These people may develop classic
chicken pox with exposure.

Vaccine information

The new vaccine (Shingrix) is
not a live virus but requires a booster 2-6 months after the first.
A slight rash can occur when receiving the vaccine.

Patients who have had severe reactions to drugs or other vaccines
(anaphylaxis) should not receive the new shingles shot without
serious discussion wit their physicians.

The shingles shot does not treat the shingles infection and should
never be received if a patient is currently enduring shingles.
Pregnant or lactating women should avoid the vaccine (no studies to
prove safety).

Although the previous vaccine protected about 50%, the new
vaccine is much more preventative (90%). The price of Shingrix is
$280 (not usually covered by insurance) for the 2 doses recommended.

Kratom is a tropical botanical evergreen tree compound (grown in
Southeast Asia—Mitragyna speciosa) that has gained popularity and
falsely claims that it can get addicts off opioids (narcotics). It
has been used in Eastern medicine for the past 2 centuries.

The FDA has just put out a warning that this compound sold in
“head” shops (vapor shops, marijuana paraphernalia shops, etc.),
although currently legal, has 22 of its
25 compounds that act like opioids. They bind the same sites
in the brain that these narcotics do and have the same psychoactive
effects.

People drink it as tea and use other methods to relieve pain, mood
up-lifting, and as an aphrodisiac. Experimenting with substances has
proven to be very dangerous.

There have been 44 deaths since November, 2017. Sadly, most of
these people had other illicit compounds in their blood stream at
autopsy as well.

The FDA states that kratom should not be used to treat medical
conditions, or used as an alternative to prescription opioids. There
is no evidence that kratom is safe.

Tell your children and all young people not to use this dangerous
compound.

The influenza bug has been as severe as the 2009 epidemic of the
swine flu. 1 in 10 doctor’s visit was for flu or flu-like symptoms
this past month. Some were testing negative early and later tested
positive. The actual flu bug changes from year to year, and it is a
bit of a guessing game each year just what specific strains need to
be covered. These viruses have a great ability to mutate making
vaccines less effective. The latest
results of coverage with the vaccine is approximately 43%.
Effectiveness for specific strains vary: Influenza A(H3N2)-25%,
Influenza A(H1N1)-67%, Influenza B(42%). The toughest strain is the
H3N2, which caused the most
significant illnesses. About a third have been protected. But that
is not the real story. The vaccine has prevented 44,000 deaths since
2009 according to the CDC. Reducing the severity of flu because of
the vaccine is very worthwhile.

The greatest effectiveness overallthis year has been in children
(59%), while those 18-49 were second (33%). 3 out of 4 children who
died were not vaccinated. As of the middle of February, 84 children
have died.

The H3N2 strain has not been around for a few years, and when it
showed up this year, the vaccine was not well protected against it
as it was for the H1N1 Influenza A and the Influenza B viral
strains, and thus the overall effectiveness was affected negatively.
These studies are all observational and have limitations, so we will
see the final outcome later in the spring.

Lack of good medications to treat viruses

It is disconcerting to not have better drug treatments for the flu
once a patient becomes symptomatic. Research dollars are not being
spent on such treatments when Big Pharma is making a killing on the
vaccine. Congress spends its research dollars on cancer, heart
disease, and other killers. Research projects go unfunded every
year.

I previously reported that Tamiflu reduced the length of the flu
by a mere half a day. Is that the best we can do?

As of February 16, the CDC still was recommending the vaccine.
www.cdc.org

This completes the March, 2018 report. Next month, the April
subjects will be: